Provider Demographics
NPI:1871295030
Name:BRISENO-VASQUEZ, MELISSA NICOLE (MSW, ACSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:NICOLE
Last Name:BRISENO-VASQUEZ
Suffix:
Gender:F
Credentials:MSW, ACSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:NICOLE
Other - Last Name:BRISENO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5014
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91413-5014
Mailing Address - Country:US
Mailing Address - Phone:818-419-0308
Mailing Address - Fax:
Practice Address - Street 1:1109 W NEWGROVE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3311
Practice Address - Country:US
Practice Address - Phone:818-419-0308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-21
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA113678104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker